Evaluation of the Functional Results in the Treatment of Pelvic Limbs with Multiple Level Surgery in Spastic ICP Patients

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Acta Ortopédica Mexicana 2010; 24(6): Nov.-Dec: 376-383

Original article

Evaluation of the functional results in the treatment of pelvic limbs with multiple level surgery in spastic ICP patients

Díaz-Vázquez J,* Peralta-Cruz S,** Olín-Núñez JA,*** Redón-Tavera A****

National Rehabilitation Institute

ABSTRACT. The purpose of this study is to RESUMEN. El objetivo de este estudio es assess the effects of multiple level surgery of the evaluar los efectos de la cirugía multinivel en pelvic limbs in patients with spastic infantile cere- extremidades pélvicas de pacientes con parálisis bral palsy seen at the National Rehabilitation In- cerebral infantil espástica, atendidos en el Insti- stitute and show that their clinical improvement tuto Nacional de Rehabilitación y demostrar que is comparable to the reports in the national and su mejoría clínica es comparable a lo reportado international literature. Material and methods: en la literatura nacional e internacional. Material cas, ya que se cambiaron

ﬁ This is a longitudinal, prospective, descriptive, y métodos: El diseño del estudio fue longitudinal, self-controlled, before-and-after clinical trial that prospectivo, descriptivo, tipo ensayo clínico au- included patients with spastic infantile cerebral tocontrolado de antes y después en pacientes con palsy who underwent multiple-level single-stage parálisis cerebral infantil espástica que fueron surgery from January 2007 to August 2008. The intervenidos con cirugía multinivel en un solo inclusion criteria were as follows: both genders, evento de Enero de 2007 a Agosto de 2008. Cri- ages 4 to 16 years, with a complete clinical file, terios de inclusión: ambos sexos, edad entre 4 y with preoperative and 8-12 month postoperative 16 años, expediente completo, rehabilitación pre y rehabilitation. Elimination criterion: any event de 8 a 12 meses postoperatoria. Criterio de elimi- not related with multiple-level surgery. Exclu- nación: evento no relacionado con la cirugía mul- sion criterion: any surgeries prior to admission. A tinivel. Criterio de exclusión: cirugías previas a car las citas de Tablas y Grá descriptive statistical analysis was used, together su ingreso. Se utilizó análisis estadístico descrip- with the Student t-test and the chi-square test. Re- tivo, t de Student y chi cuadrada. Resultados: 81 sults: 81 patients with a mean age of 7 ± 3.2, an pacientes con edad promedio de 7 ± 3.2 con rango age range of 4-16 years; 60.5% males and 39.5% de 4-16 años, masculino 60.5% y femenino 39.5%. females. The subtypes of spastic infantile cerebral Subtipos de parálisis cerebral infantil espástica: palsy were as follows: biparesis 64.2%, quadripa- diparesia 64.2%, cuadriparesia 22.2%, hemipa-

Nota: favor de veri ﬁ resis 22.2%, hemiparesis 8.6%, double hemipare- resia 8.6%, doble hemiparesia 4.9%. Los cam-

igual que en la versión español (Revisar contra revista impresa) sis 4.9%. The clinical-surgical classification (14) bios de la clasifi cación clinico-quirúrgica (14) se changed as a result of improvement and according modifi caron a la mejoría de acuerdo al número to the number of surgical procedures: 6 patients de procedimientos quirúrgicos: de un proced- (7.4%) had signifi cant improvement (p = 0.13) with imiento fueron 6 pacientes (7.4%) con mejoría one procedure; 44 patients (54.3%) had signifi cant significativa (p = 0.13), con dos procedimientos www.medigraphic.org.mx Level of evidence: IV (Act Ortop Mex, 2010) * Staff physician, Regional Hospital, Ministry of Health, Lagos de Moreno, Jalisco ** Coordinator of the Infantile Cerebral Palsy Clinic, National Rehabilitation Institute ***Assistant Director of Orthopedics, National Rehabilitation Institute ****Head of the Pediatric Orthopedics Service, National Rehabilitation Institute

Please address all correspondence to: Javier Díaz-Vázquez. Hospital Regional S.S. Lagos de Moreno Jalisco Tel.: (474)7423879/7423508 C.P. 47400; E-mail: [email protected] Este artículo puede ser consultado en versión completa en http://www.medigraphic.com/actaortopedica

376 Evaluation of the functional results in the treatment of pelvic limbs with multiple level surgery in spastic ICP patients

improvement (p = 0.002) with two procedures; 28 44 pa cientes (54.3%) con mejoría signifi cativa (p patients (34.6%) had signifi cant improvement (p = = 0.002), con tres procedimientos a 28 pacientes 0.04) with three procedures, and 3 patients (3.7%) (34.6%), con mejoría signifi cativa (p = 0.04), con had signifi cant improvement (p = 0.19) with four cuatro procedimientos a 3 pacientes (3.7%) con procedures. On the other hand, when the number mejoría signifi cativa (p = 0.19). Por otra parte al of surgical procedures was related with the diag- cruzar el número de procedimientos quirúrgicos nostic subtype of spastic infantile cerebral palsy, por subtipo del diagnóstico de parálisis cerebral in those undergoing one procedure the clinical- infantil espástica en los que tuvieron un proced- surgical classifi cation did not change in the cases imiento la clasifi cación clinico-quirúrgica no se of biparesis (p = 0.26), hemiparesis (p = 0.18), and modifi có signifi cativamente en los casos de dipa- double hemiparesis (p = 0.50). In those undergo- resia su mejoría signifi cativa (p = 0.26), hemipa- ing two surgical procedures the signifi cant chang- resia (p = 0.18), doble hemiparesia (p = 0.50); en es occurred for the cases of biparesis (p = 0.20), los que tuvieron dos procedimientos quirúrgicos quadriparesis (p = 0.007), and double hemiparesis los cambios signifi cativos sucedieron en la dipa- (p = 0.16). In those undergoing four procedures resia (p = 0.0001), cuadriparesia (p = 0.003), pero no changes occurred in the cases of biparesis (p = no en la doble hemiparesia (p = 0.50); y en los que 0.26) and hemiparesis (p = 0.50). Discussion: An tuvieron tres cirugías los cambios signifi cativos improvement in the clinical-surgical classifi cation sucedieron en la diparesia (p = 0.020), cuadripa- was observed (p = 0.0001) based on the results of resia (p = 0.007), doble hemiparesia (p = 0.16) y Gazi Zorer, as well as a signifi cant improvement los de cuatro cirugías no hubo cambios en la dipa- (p < 0.001) and an improvement reported by the resia (p = 0.26) ni en las hemiparesias (p = 0.50). gait analysis by the following authors: Ugur Sayli, Discusión: Se apreció mejoría en la clasifi cación Gouth, MA Khan. clinico-quirúrgica (p = 0.0001) a lo obtenido de Gazi Zorer a una mejoría signifi cativa (p < 0.001) y la mejoría reportada con los análisis de marcha por los autores: Ugur Sayli, Gouth, MA Khan.

Key words: muscle spasticity, surgery, cerebral Palabras clave: espasticidad muscular, cirugía, palsy, osteotomy, tenotomy. parálisis cerebral, osteotomía, tenotomía.

Introduction the results of surgery are less rewarding.3 The technique and the management of spasticity used in children with ICP are The neuromotor disorders caused by brain lesions are driven mainly by the clinical and surgical breakthroughs one of the serious problems of childhood and are amongst with the main purpose being that the correction should im- the main pediatric disabling conditions.1 In Mexico we do prove the articular deformity, the torsional deformity and not have accurate ﬁ gures on the prevalence of infantile ce- the abnormal motor control.4 rebral palsy. The report of the Ministry of Health in 1998- The purpose of the treatment of spasticity is to re- 2002 was 3 per 10,000 live births.2 From January 1st, 2006 to duce the contracture deformity, improve the patient’s October 30, 2008, according to the overall discharge report function and relieve pain. The simultaneous correction of the National Rehabilitation Institute, 112 patients with a of deformities of spastic ICP in multiple joints has been diagnosis of infantile cerebral palsy (ICP) received medi- recommended by Reimer-Blek and Rang,5 and has been cal care. The basis for treatment lies in the analysis of the supported by other authors. This method causes less mor- condition to determine which partswww.medigraphic.org.mx of it may be corrected bidity, reduces the hospital stay, facilitates the ambula- and which may not, and thus the problem of managing spas- tion and quality of the gait, reduces spasticity, provides ticity in children with spastic ICP. In children under age 4, articular alignment and congruence, decreases the use of physical therapy, orthosis or botulinum toxin injections are orthoses and simplifies the postoperative rehabilitation.5 recommended. Children develop a mature gait pattern at 4-6 The concept in multiple level surgery refers to the cor- years of age and are capable of cooperating with a postoper- rection of all the deformities (soft tissues and bones in ative physical therapy program, so the management of spas- a single surgical stage). This procedure integrates two ticity and contractures should include orthopedic surgery of prevalent concepts: Dr. Takashi Matzuo’s orthopedic se- the pelvic limbs at these ages and for thoracic limbs at 6-8 lective spasticity-control surgery,3 based on the concept years of age. Once this window of opportunity has been lost, of multiarticular muscles, which have less anti-gravity

ACTA ORTOPÉDICA MEXICANA 2010; 24(6): 376-383 377 Díaz-Vázquez J et al activity and are hyperactive in cerebral palsy. The spastic The purpose of this paper is to show that the simul- movements can therefore be controlled upon selectively taneous correction of the gross motor function in the releasing them. The monoarticular muscles, which have pelvic limbs through multiple level surgery performed anti-gravity activity and are responsible for maintaining at a single stage in bony and soft tissues is effective to an upright position, are carefully preserved. The second improve gait because it provides a more efficient use of concept refers to the bone correction (e.g., hip sublux- energy and improves the overall quality of life of the pa- ation, femoral anteversion, tibial torsion and hind foot tient with spastic ICP, in children treated at the National valgus), as proposed by Dr. James Gage.3 Rehabilitation Institute.

Table 1. Clinical classiﬁ cation. Measurement – Sex.

Measurement Total Clinical Preoperative Postoperative Preoperative Gender classiﬁ cation n (%) n (%) n (%)

Male Grade I A 0 (0.0) 5 (10.2) 5 (5.1) Grade I B 4 (8.2) 7 (14.3) 11 (11.2) Grade II A 2 (4.1) 7 (14.3) 9 (9.2) Grade II B 3 (6.1) 1 (2.0) 4 (4.1) Grade II C 0 (0.0) 5 (10.2) 5 (5.1) Grade II D 8 (16.3) 3 (6.1) 11 (11.2) Grade III A 1 (2.0) 5 (10.2) 6 (6.1) Grade III B 4 (8.2) 4 (8.2) 8 (8.2) Grade III C 15 (30.6) 8 (16.3) 23 (23.5) Grade IV A 8 (16.3) 4 (8.2) 12 (12.2) Grade IV B 4 (8.2) 0 (0.0) 4 (4.1) Total 49 (100.0) 49 (100.0) 98 (100.0) P= 0.0001 Female Grade I A 0 (0.0) 3 (9.4) 3 (4.7) Grade I B 2 (6.3) 8 (25.0) 10 (15.6) Grade II A 6 (18.8) 3 (9.4) 9 (14.1) Grade II B 1 (3.1) 2 (6.3) 3 (4.7) Grade II C 1 (3.1) 0 (0.0) 1 (1.6) Grade II D 1 (3.1) 3 (9.4) 4 (6.3) Grade III A 1 (3.1) 7 (21.9) 8 (12.5) Grade III B 10 (31.3) 0 (0.0) 10 (15.6) Grade III C 4 (12.5) 5 (15.6) 9 (14.1) Grade IV A 5 (15.6) 1 (3.1) 6 (9.4) Grade IV B 1 (3.1) 0 (0.0) 1 (1.6) Total 32 (100.0) 32 (100.0) 64 (100.0) P = 0.0001

Transposición tibial 1 64.2% anterior 60 Fasciotomía plantar 2.5 Grice 3.7

Transposición tibial 8.6 40 posterior Vulpius 9.9 Porcentaje 22.2% OVDR 30.9

www.medigraphic.org.mxIntervenciones 20 ATA 35.8 8.6% Tenotomías 4.9% de isquiotibiales 59.3 0 Tenotomías de Diparesia Cuadriparesia Hemiparesia Doble hemipa- aductores y psoas 82.7 espástica espástica espástica resia espástica 0 20 40 60 80 100 Diagnóstico Porcentaje

Chart 1. Distribution of the frequencies of the diagnosed subtypes of in- Chart 2. Distribution of the frequencies of the types of multiple level sur- fantile cerebral palsy. geries performed in patients with infantile cerebral palsy.

ACTA ORTOPÉDICA MEXICANA 2010; 24(6): 376-383 378 Evaluation of the functional results in the treatment of pelvic limbs with multiple level surgery in spastic ICP patients

Material and methods Preoperatoria Grado IVB 6.2 Postoperatoria This is a longitudinal, prospective, descriptive, before-and- Grado IVA 6.2 after self-controlled, clinical trial-like intentional intervention 16 16 study. The records of 81 patients were reviewed from Janu- Grado IIIC 23.5 ary 2007 to August 2008. The patient enrollment time line 4.9 Grado IIIB 17.3 was followed and the individual form was ﬁ lled out with the 14.8 following inclusion criteria: children ages 4 to 16 years old, Grado IIIA 2.5 males and females, with preoperative and postoperative re- 7.4 Grado IID 11.1 habilitation, with an 8-12 month postoperative follow-up pe- P = 0.0001

cación clínica cación 6.2 riod, with a clinical and surgical classifi cation (Table 1) upon fi Grado IIC 1 3.7 admission, and reassessment at postoperative months 8-12, Clasi Grado IIB 4.9 with complete records, subtype of cerebral palsy and surgical Grado IIA 12.3 procedures to be performed: adductor and psoas tenotomies, 9.9 18.5 hamstring tenotomies, derotating varus osteotomy, tibial Grado IB 7.4 transposition, plantar fasciotomy, lengthening of the calca- Grado IA 9.9 neal tendon and extraarticular arthrodesis (Grice) according to each case’s needs. The elimination criterion included 0 5 10 15 20 25 complications or another event not related with multiple level Porcentaje surgery. The exclusion criteria included having undergone surgery prior to admission to the National Rehabilitation In- Chart 3. Change from the preoperative to the postoperative clinical classifi cation after multiple level surgery in patients with ICP. stitute and not having a complete record for evaluation.

Table 2. Clinical classiﬁ cation. Measurement – Diagnosis.

Measurement Total Clinical Preoperative Postoperative Preoperative Diagnosis classiﬁ cation n (%) n (%) n (%)

Spastic biparesis Grade I A 0 (0.0) 3 (5.8) 3 (2.9) Grade I B 3 (5.8) 13 (25.0) 16 (15.4) Grade II A 6 (11.5) 9 (17.3) 15 (14.4) Grade II B 3 (5.8) 3 (5.8) 6 (5.8) Grade II C 0 (0.0) 4 (7.7) 4 (3.8) Grade II D 7 (13.5) 6 (11.5) 13 (12.5) Grade III A 2 (3.8) 10 (19.2) 12 (11.5) Grade III B 12 (23.1) 4 (7.7) 16 (15.4) Grade III C 19 (36.5) 0 (0.0) 19 (18.3) Total 52 (100.0) 52 (100.0) 104 (100.0) P = 0.0001

Spastic quadriparesis Grade III C 0 (0.0) 13 (72.2) 13 (36.1) Grade IV A 13 (72.2) 5 (27.8) 18 (50.0) Grade IV B 5 (27.8) 0 (0.0) 5 (13.9) Total 18 (100.0) 18 (100.0) 36 (100.0) P= 0.0001

Spastic hemiparesis Grade I A 0 (0.0) 3 (42.9) 3 (21.4) Grade I B 2 (28.6) 2 (28.6) 4 (28.6) Grade II A 2 (28.6) 1 (14.3) 3 (21.4) Grade II B 1 (14.3) 0 (0.0) 1 (7.1) Grade IIwww.medigraphic.org.mx C 0 (0.0) 1 (14.3) 1 (7.1) Grade II D 2 (28.6) 0 (0.0) 2 (14.3) Total 7 (100.0) 7 (100.0) 14 (100.0) P= 0.19

Double Grade I A 0 (0.0) 2 (50.0) 2 (25.0) spastic hemiparesis Grade I B 1 (25.0) 0 (0.0) 1 (12.5) Grade II C 1 (25.0) 0 (0.0) 1 (12.5) Grade III A 0 (0.0) 2 (50.0) 2 (25.0) Grade III B 2 (50.0) 0 (0.0) 2 (25.0) Total 4 (100.0) 4 (100.0) 8 (100.0) P= 0.0001

ACTA ORTOPÉDICA MEXICANA 2010; 24(6): 376-383 379 Díaz-Vázquez J et al

Table 3. Clinical classiﬁ cation. Measurement – Diagnosis.

Measurement Total No. of Clinical Preoperative Postoperative Preoperative interventions Diagnosis classiﬁ cation n (%) n (%) n (%) 1 Spastic biparesis Grade I A 0 (0.0) 1 (50.0) 1 (25.0) Grade I B 1 (50.0) 0 (0.0) 1 (25.0) Grade II A 0 (0.0) 1 (50.0) 1 (25.0) Grade III A 1 (50.0) 0 (0.0) 1 (25.0) Total 2 (100.0) 2 (100.0) 4 (100.0) Spastic hemiparesis Grade I A 0 (0.0) 2 (66.7) 2 (33.3) Grade I B 2 (66.7) 1 (33.3) 3 (50.0) Grade II A 1 (33.3) 0 (0.0) 1 (16.7) Total 3 (100.0) 3 (100.0) 6 (100.0) Double spastic Grade I A 0 (0.0) 1 (100.0) 1 (50.0) hemiparesis Grade II C 1 (100.0) 0 (0.0) 1 (50.0) Total 1 (100.0) 1 (100.0) 2 (100.0) 2 Spastic biparesis Grade I A 0 (0.0) 2 (6.7) 2 (3.3) Grade I B 2 (6.7) 9 (30.0) 11 (18.3) Grade II A 5 (16.7) 4 (13.3) 9 (15.0) Grade II B 2 (6.7) 2 (6.7) 4 (6.7) Grade II C 0 (0.0) 2 (6.7) 2 (3.3) Grade II D 4 (13.3) 2 (6.7) 6 (10.0) Grade III A 0 (0.0) 7 (23.3) 7 (11.7) Grade III B 6 (20.0) 2 (6.7) 8 (13.3) Grade III C 11 (36.7) 0 (0.0) 11 (18.3) Total 30 (100.0) 30 (100.0) 60 (100.0)

Spastic quadriparesis Grade III C 0 (0.0) 7 (70.0) 7 (35.0) Grade IV A 7 (70.0) 3 (30.0) 10 (50.0) Grade IV B 3 (30.0) 0 (0.0) 3 (15.0) Total 10 (100.0) 10 (100.0) 20 (100.0)

Spastic hemiparesis Grade I A 0 (0.0) 1 (33.3) 1 (16.7) Grade I B 0 (0.0) 1 (33.3) 1 (16.7) Grade II A 1 (33.3) 0 (0.0) 1 (16.7) Grade II C 0 (0.0) 1 (33.3) 1 (16.7) Grade II D 2 (66.7) 0 (0.0) 2 (33.3) Total 3 (100.0) 3 (100.0) 6 (100.0) P = 0.0001

2 Double spastic Grade I A 0 (0.0) 1 (100.0) 1 (50.0) hemiparesis Grade I B 1 (100.0) 0 (0.0) 1 (50.0) Total 1 (100.0) 1 (100.0) 2 (100.0) 3 Spastic biparesis Grade I B 0 (0.0) 3 (16.7) 3 (8.3) Grade II A 1 (5.6) 3 (16.7) 4 (11.1) Grade II B 1 (5.6) 1 (5.6) 2 (5.6) Grade II C 0 (0.0) 2 (11.1) 2 (5.6) Grade II D 2 (11.1) 4 (22.2) 6 (16.7) Grade III A 1 (5.6) 3 (16.7) 4 (11.1) Grade III B 6 (33.3) 2 (11.1) 8 (22.2) Grade III C 7 (38.9) 0 (0.0) 7 (19.4) Total 18 (100.0) 18 (100.0) 36 (100.0) Spastic quadriparesis Grade III C 0 (0.0) 6 (75.0) 6 (37.5) Grade IV A 6 (75.0) 2 (25.0) 8 (50.0) Grade IV B 2 (25.0) 0 (0.0) 2 (12.5) Total 8 (100.0) 8 (100.0) 16 (100.0)

Double spastic www.medigraphic.org.mx Grade III A 0 (0.0) 2 (100.0) 2 (50.0) hemiparesis Grade III B 2 (100.0) 0 (0.0) 2 (50.0) Total 2 (100.0) 2 (100.0) 4 (100.0)

4 Spastic biparesis Grade I B 0 (0.0) 1 (50.0) 1 (25.0) Grade II A 0 (0.0) 1 (50.0) 1 (25.0) Grade II D 1 (50.0) 0 (0.0) 1 (25.0) Grade III C 1 (50.0) 0 (0.0) 1 (25.0) Total 2 (100.0) 2 (100.0) 4 (100.0)

Spastic hemiparesis Grade II A 0 (0.0) 1 (100.0) 1 (50.0) Grade II B 1 (100.0) 0 (0.0) 1 (50.0) Total 1 (100.0) 1 (100.0) 2 (100.0)

ACTA ORTOPÉDICA MEXICANA 2010; 24(6): 376-383 380 Evaluation of the functional results in the treatment of pelvic limbs with multiple level surgery in spastic ICP patients

Medición Medición 25 66.7 Núm. intervenciones 25 Núm. intervenciones 22.7 1 antes 2 antes 60 1 después 2 después 20 50 15.9 15.9 15.9 15 13.6 13.6 40 13.6 Porcentaje 9.1 10 9.1 Media porcentaje 6.8 6.8 20 16.7 16.716.7 16.7 16.7 6.8 6.8

5 4.5 4.5 4.5 4.5

0 0 IA IB IIAIIC IIIA IA IIA IIC IIIA IIIC IVB IB IIB IID IIIB IVA Clasiﬁ cación clínica Clasiﬁ cación clínica One surgery p = 0.13 Two surgeries p = 0.002

30 Medición Medición Núm. intervenciones 28.6 66.7 Núm. intervenciones 3 antes 4 antes 25 3 después 60 4 después 21.4 21.4 20 17.9 40

14.3 33.3 33.3 33.3 33.3 10.7 10.7 Media porcentaje

10 Media porcentaje

7.1 7.1 7.1 7.1 7.1 20 3.6 3.6 3.6 3.6

0 0 IB IIB IID IIIB IVA IB IIA IIB IID IIIC IIA IIC IIIA IIIC IVB Chart 4. Showing the changes in the Clasifi cación clínica Clasifi cación clínica clinical classifi cation according to the Three surgeries p = 0.04 Four surgeries p = 0.19 number of surgical interventions.

Statistical analysis: descriptive statistics were used (fre- EsteThe documento changes towards es elaborado an improvement por Medigraphic in the clinical clas- quency, percentage) and for the hypothesis tests the chi sifi cation were the same regardless of the sex of patients, square test, the Student t test and the one-way variance anal- i.e., they were equally signifi cant in both males and females ysis sere used. The differences were considered as signifi - (Table 1). cant when p = 0.005. According to the subtype of ICP, the changes were signifi cant in the cases of biparesis and quadriparesis but they Results were not signifi cant in the cases of hemiparesis and double hemiparesis (Table 2). This is a sample of 81 patients with a mean age of 7 ± 3.2 According to the number of interventions, one may see years with a range of 4 to 16 years. 60.5% were males and that the changes in the clinical classifi cation at both ends 39.5% females. The subtypes of ICP diagnosed are included (those with a single surgery and those with four surgeries) in chart 1. www.medigraphic.org.mxwere not signifi cant, probably because of the small sample The most frequent interventions were: first of all, ad- size (Table 3 and Chart 4). ductor and psoas tenotomies; second, hamstring tenoto- Overall, 6 patients (7.4%) underwent a single surgery, mies; third, lengthening of the calcaneal tendon, and 44 (54.3%) two surgeries, 28 (34.6%) three surgeries, and 3 fourth, derotating varus osteotomy; the rest of the proce- (3.7%) four surgeries. dures, such as tibial transposition, extraarticular arthrod- The mean age was signifi cantly different according to the esis (Grice) and plantar fasciotomy, were performed in number of surgeries, with 9.3 ± 4.2 for those undergoing less than 10% (Chart 2). a single surgery; 6.8 ± 2.8 for two surgeries, 6.4 ± 3.2 for The clinical classifi cation was modifi ed signifi cantly to- three surgeries, and 11.3 ± 2.5 for those who underwent four wards a clear improvement (Chart 3). surgeries (p = 0.02).

ACTA ORTOPÉDICA MEXICANA 2010; 24(6): 376-383 381 Díaz-Vázquez J et al

Table 4. Universal clinico-surgical classiﬁ cation of patients with spastic ICP Dr. Redón – Tavera.

Clinical Improvement means moving from one grade to another

Grade I – Mild Grade I - A Independent gait without contractures or walking aids (attitude very close to normal). Grade I - B Independent gait, without subclinical isolated contracture. a) Single-limb spasticity. b) Absence of fi ne voluntary control in one hand. c) Excessive wear of the tip of one shoe (spastic retraction of sural muscles and insuffi cient foot dorsifl exion)

Grade II – Moderate Grade II - A Independent gait with dynamic contractures; aligned on the table. a) Walking with a spastic attitude (scissor gait) without assistance. b) Achieves complete ranges of passive motion. Grade II - B Independent gait with dynamic established contractures; contractured on the table. a) Walks with a spastic attitude (scissor gait). b) Does not achieve complete ranges of passive motion. Grade II - C Independent gait without contractures, assisted gait. a) Aligned postoperated child. b) Not strong enough to stand up. c) Gait assisted with hands and aids. Grade II - D Independent gait with contractures, assisted gait. a) Persistent contractures. b) Requires walking aids. c) Insufﬁ cient strength to maintain vertical bipedestation. d) Moves with bipodalic weight bearing.

Grade III – Severe Grade III - A Dependent weight bearing and gait refl ex, no contractures. a) Insuffi cient trunk strength and balance. b) Requires assistance (a person, wall, rail or furniture). c) Cannot use walker or crutches. Grade III - B Dependent weight bearing and gait refl ex, with contractures. a) Insuffi cient strength to stand up on their own. b) Needs gait assistance. c) Adopts sitting position. Grade III - C Impossible gait, sitting trunk balance with contractures a) No weight bearing or gait refl ex b) May sit down with a balanced trunk.

Grade IV – Severe

Grade IV - A No trunk balance, full assistance. a) Cannot hold the head and the trunk. b) Flaccidity of pelvic limbs. c) Spasticity of pelvic segments. d) Frequent mental impairment. Grade IV - B Spastic scoliosis a) Bipedestation impossible. b) Cannot sit down.

On the other hand, when the number of surgeries was those who underwent four surgeries there were no changes related with the ICP diagnostic subtype, in those who under- in biparesis (p = 0.26) and hemiparesis (p = 0.50) (Table 2). went one surgery the clinical classiwww.medigraphic.org.mxfi cation did not change signifi cantly in the cases of biparesis (p = 0.26), hemipare- Discussion sis (p = 0.18) and double hemiparesis (p = 0.50); in those who underwent two surgeries the signifi cant changes in the The brain neurologic damage in children has become clinical classifi cation occurred for biparesis (p = 0.0001) a public health problem6 due to its high incidence that is and quadriparesis (p = 0.003), but not for hemiparesis (p partly due to the high survival rate of high risk neonates, = 0.19) or double hemiparesis (p = 0.50); in those who un- and to the functional sequelae that are usually detected derwent three surgeries, the signifi cant clinical changes also late.7 Thus the health care institutions have established a occurred for biparesis (p = 0.020), and quadriparesis (p = standardization protocol using the gait-related technologi- 0.007), but not for double hemiparesis (p = 0.16); fi nally, in cal developments and the rehabilitation programs as well as

ACTA ORTOPÉDICA MEXICANA 2010; 24(6): 376-383 382 Evaluation of the functional results in the treatment of pelvic limbs with multiple level surgery in spastic ICP patients those that include guidance on functional skills and quality family. We therefore confi rm that our functional results are of life measures.3,8-11 The purpose of this study is to assess comparable to those published in the international medi- the functional and clinical results of the treatment of pelvic cal literature.10-13 The postoperative functional result 8-12 limbs with multiple level surgery in spastic patients selected months after the surgery was a clear improvement with a by applying a previously defi ned standardized protocol at signifi cant p = 0.0001 (Chart 3). Clinically, local improve- the National Rehabilitation Institute. Also, to compare the ment was seen when they continued to be classifi ed in the results obtained in studies reported by other authors: Dr. same grade and an overall improvement when they moved Metaxiotis9 in a study of 20 children (40 pelvic limbs) with to a different grade (Grade III to Grade II). spastic ICP who underwent multiple level surgery showed an excellent improvement in the 3D gait analysis performed Conclusion before and after the surgery.12 Andi B. Gordon did a study to determine the effi cacy of percutaneous tenotomy surgery in This study shows the improvement of pediatric patients with children with ICP (ambulatory) from 1996 to 2007 and as- cerebral palsy in different stages. Individualized surgical treat- sessed 50 patients. He showed a signifi cant improvement in ment plays an important role in the prevention of deformities, knee extension, increased velocity, longer strides and over- improves the muscular balance and allows for positive changes all improved gait in the short term (less than 18 months after in the universal clinico-surgical classifi cation (Table 4).14 the surgery) and in the long term (after postoperative month 18) and showed effi cacy with the 3D computed gait analy- References 12 sis performed before and after the surgery. Gazi Zorer as- 1. Guerrero ZB, Martínez LR: Integración de personas con discapacidad: sessed the results of multiple level surgery in 23 patients Sin diferencias. 2005; 5(15): 6-16. with a mean age of 6 years, with a range of 4 to 17 years, 2. Redón TA, Medinaveitia VJA, Arellano SE, Olín NA, Viñals LC, Pe- and reported an improvement in patients’ posture and gait; ralta CS, Del Valle CMG, Vázquez EJ: Clínica de parálisis cerebral infantil en el Instituto Nacional de Rehabilitación. Acta Ortop Mex it became easier for them to use a walker and crutches. He 2006; 20(4): 145-9. evaluated the results with the gross motor function classifi - 3. Matsuo T: Cerebral palsy: Spasticity-control and orthopaedics. cation.13 Gouth assessed 24 patients under 7 years of age; An introduction to orthopaedic selective spasticity-control surgery 13 children accepted his surgery (surgical group) and 11 (OSSCS), Soufusha, Tokyo, 2002. 4. Koman LA, Smith BP, Shilto JS: Cerebral Palsy. Lancet 2004; 363: did not (non-surgical group). Patients in the surgical group 1619-31. had improvement in the ranges of motion of the pelvic limb 5. Ugur Sayli, Sinan, Ayse: Simultaneous multiple operations for the joints, when compared with the results of the non-surgical lower extremity contractures of spastic cerebral palsied patients: Kli- group.10 M. A. Khan assessed 85 patients ages 5 to 12 years nik Arastirma/Clinical Research 1999; 10(2): 160-4. 6. Universia México: Parálisis cerebral, primer lugar de discapacidad en who could not walk and performed single-stage multiple niños. Boletín Red de Universidades Red de Oportunidades. 2007. level surgery. The assessments performed 2-5 years after 7. Renshaw TS, Green NE, Griffi n PP, Lee R: Cerebral palsy: Orthopae- surgery, with a mean of 3.5 years, found that the contracture dic management. J Bone Joint Surgery Am 2008; 77: 1590-606. levels in the static joints had resolved when gait improved.11 8. Sharan D: Recent advances in management of cerebral palsy: Indian J Paediatric 2005; 72(11): 969-73. In this study Grade IV patients could easily change their 9. Metaxiotiis D, Wolf S, Doederlein L: Conversion of biarticular to mo- position and remained pain free after treatment. Grade III noarticular muscles as a component of multilevel surgery in spastic patients were able to walk with minimal assistance and/or displegia: J Bone Joint Surg Br 2004; 86-B(1): 102-9. had independent gait with contractures. Grade II patients 10. Gough M: The outcome of surgical intervention for early deformity in young ambulant children with bilateral spastic cerebral palsy. J Bone had improvement towards independent gait, subclinical con- Joint Surg Br 2008; 90-B(7): 946-51. tractures and more easiness in using a walker or an exter- 11. Khan MA: Event multilevel surgery in untreated cerebral palsy in a nal aid. Grade I-B patients had a remarkable improvement developing country. J Bone Joint Surg Br 2007; 89-B(8): 1088-91. towards independent gait without contractures or assisted 12. Gordon AB, Glen OB: Gait analysis outcomes of percutaneous medial hamstring tenotomies in children with cerebral palsy: J Paediatric Or- 14 gait. This clinico-surgical classifi cation is very objective thop 2008; 28(3): 324-9. because it allows us to make a clinical assessment of the pa- 13. Zorer G, Cemal D: The results of single-stage multilevel muscle-ten- tient with dependent or independent gait, as well as an exam don surgery in the lower extremities of patients with spastic cerebral in dorsal decubitus and thus determine the corresponding palsy. Acta Orthop Traumatol Turc 2004; 38(5): 317-25. 14. Redón TA: Universal two stage clinical-surgical classifi cation for pa- pre- and postoperative grade; thewww.medigraphic.org.mx clinical improvement was tients who have cerebral palsy. Tachdjian 22 Paediatric Orthopaedic. confi rmed by the subjective assessment by patients and their 1994; 1: 109-15.

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